Evaluating medically at-risk drivers: a survey of assessment practices in Canada.

BACKGROUND: Assessing medical fitness to drive (FTD) can include both off- and on-road testing, although consistency of practice is unclear. PURPOSE: To examine actual practices being used to assess FTD at driver assessment centres (DACs) across Canada. METHOD: Surveys e-mailed to 90 DACs were returned by 47 assessors. FINDINGS: The majority of respondents (89%) were occupational therapists. Assessors reported doing an average of eight FTD assessments per month (range = I to 40) at an average cost of $366 (SD = $225; range = $40 to $985). Referrals came from physicians (96%), other health professionals (70%), and licensing authorities (66%). Clients with stroke, dementia, traumatic brain injury, mild cognitive impairment, and multiple sclerosis composed 62% of estimated caseloads. Assessments took 3 hr on average (range = 1.24 to 4.5 hr); 64% reported they always took clients on road regardless of clinic results. IMPLICATIONS: Evidence-based guidelines for training and assessment are clearly needed given the inconsistency in practice.

Examination of driving comfort and self-regulatory practices in older adults using in-vehicle devices to assess natural driving patterns.

Several studies have shown that age, gender, visual problems and confidence are associated with self-regulatory practices such as reduced exposure and avoidance of night and highway driving. To date, however, self-regulation has only been examined through self-report. The purpose of this study was to further our understanding of the association between driver characteristics, perceptions and self-regulation by monitoring the patterns of 61 drivers (mean age 80.4+/-5.5; 59% women) for one week using in-vehicle devices. Usual self-regulatory practices were assessed using the Situational Driving Frequency (SDF) and Avoidance (SDA) Scales, while perceptions were measured using the Driving Comfort and Perceived Driving Abilities Scales. Additional evidence for test-retest reliability was obtained with a separate sample of 39 older drivers. Lower comfort and poorer perceived abilities were significantly related to actual behavior: reduced exposure (km, duration) in general and at night, average and maximum radii from home and driving in challenging situations (such as on highways). Neither sex nor age was associated with any of the driving indicators. While longitudinal studies are required to determine temporality (when drivers change their behavior) and directionality (does lower comfort lead to driving restrictions or vice versa), this is the first study to demonstrate that driver perceptions are associated with actual self-regulatory practices.

Correspondence between self-reported and objective measures of driving exposure and patterns in older drivers.

The driving behavior of older adults has been traditionally examined using questionnaires and diaries. The accuracy of self-reports has been questioned, and in-vehicle recording devices touted as more objective measures of real-world driving. The purposes of this study were to replicate and extend prior research comparing self-report and actual measures of driving exposure and patterns. Two electronic devices were installed in the vehicles of 61 drivers (67-92 years, 59% women) who were instructed to drive as usual over 1-week. Participants completed trip logs, daily diaries, a questionnaire on usual driving habits, ratings of situational driving frequency and avoidance and a follow-up interview. Only 53% of the sample attempted to estimate how far they had driven over the week and self-estimates were inaccurate (ME=77.5 km; CV=44.5%). Drivers tended to miss a significant number of trips and stops in their diaries. Driving behavior over the week was fairly consistent with usual practices regarding time of day, driving in certain areas, and night driving. However, subjects drove in challenging situations more than usual. Triangulating multiple sources of electronic and self-reported data provided a better understanding about the behavior of older drivers.

Conceptualizing and measuring confidence in older drivers: development of the day and night driving comfort scales.

OBJECTIVE: To examine and measure driving confidence from the perspective of older adults. DESIGN: Used focus groups for construct examination, item generation, and ratings; conducted psychometric testing using Rasch analysis for scale refinement; examined test-retest reliability and associations with driver characteristics and driving habits. SETTING: Retirement complexes and seniors' housing and centers in Ontario, Canada. PARTICIPANTS: Convenience samples of current drivers (n=143) (range, 66-92y) and 7 counselors. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Day (DCS-D) and Night (DCS-N) Driving Comfort Scales developed inductively with older drivers. RESULTS: Older drivers believed that it was important to consider confidence in their own abilities and discomfort caused by other drivers, to separate day and night driving, and to specify the driving context (eg, traffic flow, speed). Rasch analysis showed that the final 13-item DCS-D and 16-item DCS-N were both hierarchic and unidimensional, with good person (.89, .96) and item (.98, .97) reliabilities, respectively. Test-retest reliability was adequate for the DCS-D (intraclass correlation coefficient [ICC]=.7) and good for the DCS-N (ICC=.88). Scores were significantly associated with reported driving frequency, situational avoidance, and perceived abilities (P<.001). CONCLUSIONS: The Driving Comfort Scales are promising new tools for research and practice.

Assessing subjective fall concerns in residential living seniors: development of the activities-specific fall caution scale.

OBJECTIVES: To examine subjective fall concerns of seniors in residential care and to develop a tool applicable to both nursing home and assisted living settings. DESIGN: Used focus groups with residents and staff for construct examination and item generation; surveyed staff and interviewed residents for item verification; and conducted psychometric testing using Rasch analysis for scale refinement. SETTING: Seventeen residential care facilities in Ontario, Canada. PARTICIPANTS: Convenience samples totaling 57 staff and 234 residents. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: The Activities-specific Fall Caution (AFC) Scale, developed inductively with residents and staff, with items pertaining to residential living (eg, moving around a room full of people, furniture, or walkers). RESULTS: Resident terms (being cautious or careful) and qualifications (whether alone and proximity of gait aids) guided tool development. Rasch analysis showed that the final 13-item AFC Scale was hierarchic and unidimensional, with good person (.86) and item (.95) reliability. CONCLUSIONS: The AFC scale is a promising new tool for assessing subjective fall concerns in residential care residents. This tool can be administered via interview in about 10 minutes to most residents with Mini-Mental State Examination scores of 12 or greater, using practice questions to determine understanding and a 4-point color response card similar to a traffic light to facilitate responding.

Reliability, construct validity, and clinical feasibility of the activities-specific fall caution scale for residential living seniors.

OBJECTIVE: To examine the reliability, validity, and feasibility of the Activities-specific Fall Caution (AFC) Scale. DESIGN: Cross-sectional studies with test-retest and interrater reliability. SETTING: Residential care facilities in Ontario, Canada: 10 in study 1 and 6 in study 2. PARTICIPANTS: Convenience samples of 101 and 31 residents. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: In study 1, the AFC Scale was readministered to 44 residents, 64 were assessed using the Berg Balance Scale, Timed Up & Go, and Self-Paced Walk Test, and the Nursing Home Life-Space Diameter was completed for 80 residents. In study 2, staff administered the AFC Scale to 31 residents on 2 occasions. RESULTS: In study 1, test-retest reliability (intraclass correlation coefficient [ICC]) was .87 (95% confidence interval, .78-.93). AFC scores were associated with physical performance and mobility patterns (P<.001) and able to discriminate on the basis of gait aid use (P<.001), balance disorders (P<.05), and transfer assistance and walk speed (P<.01). Comparatively, general fear of falling showed weaker associations and a sex bias. In study 2, staff administration was fairly consistent (ICC=.71) and similar associations emerged for AFC scores. CONCLUSIONS: The AFC Scale shows good reproducibility, convergent and discriminative validity, and is feasible for clinical as well as research use.